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Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017;6(2):e000096doi: 10.1136/bmjoq-2017-000096.
Murphy, M., Duff, J., Whitney, J., Canales, B., Markham, M. J., & Close, J. (2017). Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ open quality, 6(2), e000096. https://doi.org/10.1136/bmjoq-2017-000096
Murphy, Martina, et al. "Implementation of a mock root cause analysis to provide simulated patient safety training." BMJ open quality vol. 6,2 (2017): e000096. doi: https://doi.org/10.1136/bmjoq-2017-000096
Murphy M, Duff J, Whitney J, Canales B, Markham MJ, Close J. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017 Oct 31;6(2):e000096. doi: 10.1136/bmjoq-2017-000096. eCollection 2017. PMID: 29450282; PMCID: PMC5699135.
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BMJ Open Qual. 2017 Oct 31;6(2):e000096. doi: 10.1136/bmjoq-2017-000096. eCollection 2017.

Implementation of a mock root cause analysis to provide simulated patient safety training.

BMJ open quality

Martina Murphy, Jennifer Duff, Julie Whitney, Benjamin Canales, Merry-Jennifer Markham, Julia Close

Affiliations

  1. Department of Medicine, Division of Hematology/Oncology, University of Florida and the North Florida/South Georgia Veterans Administration (NF/SGVA), Gainesville, Florida, USA.
  2. North Florida/South Georgia Veterans Administration, Gainesville, Florida, USA.
  3. Department of Urology, University of Florida and the North Florida/South Georgia Veterans Administration (NF/SGVA), Gainesville, Florida, USA.
  4. Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainesville, Florida, USA.

PMID: 29450282 PMCID: PMC5699135 DOI: 10.1136/bmjoq-2017-000096

Abstract

BACKGROUND: The proposed revision to the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements includes participation in real or simulated patient safety activities, such as root cause analysis (RCA).1 Because exposure to RCA may occur with low frequency, a mock RCA was developed and piloted for feasibility with Hematology/Oncology fellows.

OBJECTIVE: To improve trainee knowledge of the goals and application of RCA in patient safety and quality improvement through a simulated experience.

METHODS: A mock RCA was implemented with Hematology/Oncology fellows over two subsequent years. In small groups, they reviewed a case involving an adverse event and identified sources of harm. Additional details, in the form of provider interviews, were available upon request. Trainees identified the root cause(s) and proposed measurable changes. Teams presented proposals to peers and a panel representing hospital leadership. Feedback was provided. Trainees completed evaluations and were surveyed regarding their perceptions.

RESULTS: Thirteen of 15 fellows completed the survey. Twelve of 13 (92%) fellows felt the mock RCA improved their comfort level for participation in a real RCA. Ten of 13 fellows (77%) reported increased awareness and likelihood of reporting near misses and/or adverse events following participation. More thorough patient care documentation following the session was reported by 8 of 13 (62%).

CONCLUSION: A pilot trial of a mock RCA with Hematology/Oncology fellows had high trainee satisfaction. Post-session surveys and informal interviews suggest trainees have reduced anxiety when faced with participation in a real RCA and have more interest in the process after participation.

Keywords: continuous quality improvement; graduate medical education; medical education; near miss; quality improvement

Conflict of interest statement

Competing interests: None declared.

References

  1. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i51-6 - PubMed
  2. Acad Med. 2006 Oct;81(10):919-24 - PubMed

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